Severe falciparum malaria causes multiple organ dysfunction including metabolic acidosis, coma, anemia, acute kidney injury (AKI), and pulmonary edema. The mortality rate of the disease is still around 15-23% despite optimal antimalarial therapy. Supportive therapy and intensive care are crucial elements in the treatment of the multiple complications of the disease. Optimal fluid therapy however, one of the fundamental elements of the supportive therapy, has not been well defined. A large randomized controlled trial of fluid therapy in shocked African children (the FEAST study) showed that fluid bolus resuscitation increased the mortality in severe malaria. A retrospective study in adult patients with severe malaria showed that fluid loading had no effect on acid-base status or renal failure. A recent study by our group showed that liberal fluid management guided by invasive monitoring was not associated with improved renal function or acid-base status, but did aggravate pulmonary edema in patients developing pulmonary capillary leakage during admission in the intensive care unit. The study found that 38% of severe malaria patients developed clinical pulmonary edema, 80% of which occurred after liberal fluid resuscitation. In this study, plasma lactate as a crude measure of tissue hypoperfusion correlated with the degree of sequestration (directly observed by OPS imaging), and not with the volume of fluid resuscitation. It was concluded that liberal fluid management is not indicated in adult severe malaria. However, this same study showed that all patients with severe malaria present with intravascular dehydration, and often have not been able to maintain proper fluid intake for a considerable time. Failure to give these patients enough fluid therapy could therefore be expected to precipitate renal failure and tissue hypoperfusion. Overall, the evidence suggests that in severe malaria, liberal fluid resuscitation is harmful despite patients often being hypovolaemic on admission. The minimum fluid therapy required to prevent complications has yet to be defined. Currently, the clinician has no guidance except for the very general adage: "keep them dry".